Trauma Admit Note

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Tier level: _ 
Time of Activation: _ 
Time of Patient Arrival: _ 
Time of Surgeon Arrival: _ 
Admitting Trauma Surgeon: _ 
ED physician involved and time of arrival: _ 
Other physicians involved and time of arrival: _ 
CT technician time of arrival: _
Anesthesiologist time of arrival: _ 
 
Age: _ 
Mechanism of Injury/Findings at scene: _
Procedures performed in field: _  
Transportation type: _ 
Last meal: _
 
Primary Survey 
Airway: [intact] 
Breathing: [normal, breath sounds equal bilaterally]  
Circulation: [skin warm, distal pulses 2+, capillary refill less than 2 seconds globally] 
Disability 
Pupils: [equal and reactive to light, _-_mm, brisk] 
GCS: [15, E=_ V=_ M=_]  
Motor Function: [move all extremities]  
Sensory: [no deficits] 
Exposure: _ 
 
Secondary Survey 
VS:  _
GEN: [well developed and well nourished] 
HEAD: [NCAT]
EYES: [pupils round reactive to light, conjunctiva clear, extraocular movements intact, no raccoons eyes]
ENT: [no fluid in external acoustic canals, no hemotympanum, no battle's sign, nares patent, oropharynx clear]
NECK: [no JVD, midline trachea, no cervical spine tenderness, C-collar in place] 
HEART: [regular rate and rhythm] 
LUNGS: [CTAB] 
CHEST: [chest wall non-tender, no bruising/deformity]
ABD: [no Grey-Turner's or Cullen's sign, soft, non tender, no rebound or guarding, E-FAST scan negative at _ ] 
PELVIS: [stable to rock] 
BACK: [no step offs or deformities, T-L spine non tender] 
GU: [no perineal hematoma, NO BLOOD AT MEATUS] 
EXT: [2+ global pulses, moving all extremities well, +5/5 muscle strength globally] 
NEURO: [CNII-XII grossly intact, no sensory deficits] 
RECTAL: [good tone, no gross blood, NO HIGH RIDING PROSTATE] 
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